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Glycemic Management in Type 2 Diabetes

Glycemic Management in Type 2 Diabetes. AACE Comprehensive Care Plan. Handelsman Y, et al. Endocr Pract . 2011;17(suppl 2):1-53. Glycemic Management in Type 2 Diabetes. Therapeutic Lifestyle Change. Components of Therapeutic Lifestyle Change. Healthful eating Sufficient physical activity

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Glycemic Management in Type 2 Diabetes

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  1. Glycemic Management in Type 2 Diabetes

  2. AACE Comprehensive Care Plan Handelsman Y, et al. Endocr Pract. 2011;17(suppl 2):1-53.

  3. Glycemic Management in Type 2 Diabetes Therapeutic Lifestyle Change

  4. Components of Therapeutic Lifestyle Change • Healthful eating • Sufficient physical activity • Sufficient sleep • Avoidance of tobacco products • Limited alcohol consumption • Stress reduction Handelsman Y, et al. Endocr Pract. 2011;17(suppl 2):1-53.

  5. AACE Healthful Eating Recommendations Handelsman Y, et al. Endocr Pract. 2011;17(suppl 2):1-53.

  6. AACE Medical Nutritional Therapy Recommendations • Consistency in day-to-day carbohydrate intake • Adjusting insulin doses to match carbohydrate intake (eg, use of carbohydrate counting) • Limitation of sucrose-containing or high-glycemic index foods • Adequate protein intake • “Heart-healthy” diets • Weight management • Exercise • Increased glucose monitoring Handelsman Y, et al. Endocr Pract. 2011;17(suppl 2):1-53.

  7. AACE Physical Activity Recommendations • ≥150 minutes per week of moderate-intensity exercise • Flexibility and strength training • Aerobic exercise (eg, brisk walking) • Start slowly and build up gradually • Evaluate for contraindications and/or limitations to increased physical activity before patient begins or intensifies exercise program • Develop exercise recommendations according to individual goals and limitations Handelsman Y, et al. Endocr Pract. 2011;17(suppl 2):1-53.

  8. Glycemic Management in Type 2 Diabetes Antihyperglycemic Therapy

  9. Noninsulin Agents Available for Treatment of Type 2 Diabetes HGP, hepatic glucose production. Inzucchi SE, et al. Diabetes Care. 2012;35:1364-1379.

  10. Noninsulin Agents Available for Treatment of Type 2 Diabetes HGP, hepatic glucose production. Inzucchi SE, et al. Diabetes Care. 2012;35:1364-1379.

  11. Insulins Available for the Treatment of Type 2 Diabetes Inzucchi SE, et al. Diabetes Care. 2012;35:1364-1379.

  12. Pharmacokinetics of Insulin Moghissi E, et al. Endocr Pract. 2013;Feb 20:1-33. [Epub ahead of print].

  13. Combination Agents Available for the Treatment of Type 2 Diabetes

  14. Principles of the AACE/ACE T2DM Algorithm Glucose Targets • Ongoing lifestyle optimization essential • Requires support from full diabetes team • Set A1C target based on individual patient characteristics and risk • ≤6.5% optimal if it can be achieved safely • Targets may change over time • FPG and PPG regularly monitored by patient with SMBG Garber AJ, et al. Endocr Pract. 2013;19:327-336.

  15. Principles of the AACE/ACE T2DM Algorithm Antihyperglycemic Medications • Choose medications based on individual patient attributes • Minimize risk of hypoglycemia • Minimize risk of weight gain • Combine agents with complimentary mechanisms of action for optimal glycemic control • Prioritize safety and efficacy over medication cost • Medication cost small portion of total cost of diabetes • Risk of adverse effects considered part of “cost” of medication • Evaluate treatment efficacy every 3 months • A1C, FPG, and PPG data • Hypoglycemia • Other adverse events (weight gain; fluid retention; hepatic, renal, or cardiac disease) • Comorbidities and complications • Concomitant drugs • Psychosocial factors affecting patient care Garber AJ, et al. Endocr Pract. 2013;19:327-336.

  16. Common Principles in AACE/ACE and ADA/EASD T2DM Treatment Algorithms • Individualize glycemic goals based on patient characteristics • Promptly intensify antihyperglycemic therapy to maintain blood glucose at individual targets • Combination therapy necessary for most patients • Base choice of agent(s) on individual patient medical history, behaviors and risk factors, ethno-cultural background, and environment • Insulin eventually necessary for many patients • SMBG vital for day-to-day management of blood sugar • All patients using insulin • Many patients not using insulin Inzucchi SE, et al. Diabetes Care. 2012;35:1364-1379. Garber AJ, et al. Endocr Pract. 2013;19:327-336.

  17. ADA/EASD T2DM Treatment Algorithm Inzucchi SE, et al. Diabetes Care. 2012;35:1364-1379.

  18. ADA/EASD T2DM Treatment Algorithm: Sequential Insulin Strategies Inzucchi SE, et al. Diabetes Care. 2012;35:1364-1379.

  19. Early Insulin Use in Type 2 Diabetes Outcome Reduction With an Initial GlargineIntervention CV risk factors + prediabetes or T2DM (N=12,537) ORIGIN Trial Investigators. N Engl J Med. 2012;367:319-328.

  20. Pipeline Classes and Agents (2013) Bakris GL, et al. Kidney Int. 2009;75:1272-1277; Calado J, et al. Kidney Int Suppl. 2011:S7-S13;Garber AJ. Expert Opin Investig Drugs. 2012;21:45-57; Goldfine AB, et al.Ann Intern Med. 2010;152:346-357;King A. J Fam Pract. 2012;61:S28-S31; Tahrani AA, et al. Lancet. 2011;378:182-197;Tahrani AA, et al. Lancet. 2012;379:1465-1467.

  21. Glycemic Management in Type 2 Diabetes Technology for Type 2 Diabetes Management

  22. SMBG in Type 2 Diabetes: AACE/ACE Recommendations Noninsulin Users • Introduce at diagnosis • Personalize frequency of testing • Use SMBG results to inform decisions about whether to target FPG or PPG for any individual patient Insulin Users • All patients using insulin should test glucose • ≥2 times daily • Before any injection of insulin • More frequent SMBG (after meals or in the middle of the night) may be required • Frequent hypoglycemia • Not at A1C target  • Testing positively affects glycemia in T2DM when the results are used to: • Modify behavior • Modify pharmacologic treatment SMBG, self-monitoring of blood glucose. Handelsman Y, et al. Endocr Pract. 2011;17(suppl 2):1-53.

  23. SMBG in Noninsulin Using Patients With T2DM 9.0 Active control group (n=227) 8.8 Structured testing group (n=256) 8.6 8.4 8.2 Adjusted Mean A1C (%) 8.0 -0.3% (P=0.04) 7.8 7.6 7.4 7.2 Baseline M1 M3 M6 M9 M12 ACG, active cotnrol group; STG, structured testing group. Polonsky WH, et al. Diabetes Care. 2011;34:262-267.

  24. CSII in Type 2 Diabetes: Patient Candidates • Absolutely insulin-deficient • Take 4 or more insulin injections a day • Assess blood glucose levels 4 or more times daily • Motivated to achieve tighter glucose control • Mastery of carbohydrate counting, insulin correction, and adjustment formulas • Ability to troubleshoot problems related to pump operation and plasma glucose levels • Stable life situation • Frequent contact with members of their healthcare team, in particular their pump-supervising physician CSII, continuous subcutaneous insulin infusion. Handelsman Y, et al. Endocr Pract. 2011;17(suppl 2):1-53.

  25. Glycemic Management in Type 2 Diabetes Surgical Intervention

  26. Surgical Intervention inType 2 Diabetes Intensive medical therapy Sleeve gastrectomy Roux-en-Y gastric bypass 20 0.0 0 -20 0.5 -40 1.0 P=0.02 -60  FPG (mg/dL) 1.5  A1C (%) -80 2.0 P<0.001 -100 P<0.001 2.5 -120 3.0 -140 P<0.001 3.5 -160 Baseline 6 12 3 9 Baseline 6 12 3 9 3.5 0 3.0 -2 2.5 Average no. diabetes medications -4 2.0  BMI (kg/m2) -6 1.5 P<0.001 P<0.001 -8 1.0 -10 0.5 P<0.001 P<0.001 0.0 -12 Baseline 6 12 3 9 Baseline 6 12 3 9 Months Months Schauer PR, et al. N Engl J Med. 2012;366:1567-1576.

  27. Glycemic Management in Type 2 Diabetes Safety Concerns: Hypoglycemia

  28. Type 2 Diabetes Pathophysiology: Origins of Hypoglycemia Cryer PE. Am J Physiol. 1993; 264(2 Pt 1):E149-E155.

  29. Hypoglycemia: Risk Factors Patient Characteristics Behavioral and Treatment Factors Missed meals Elevated A1C Insulin or sulfonylurea therapy • Older age • Female gender • African American ethnicity • Longer duration of diabetes • Neuropathy • Renal impairment • Previous hypoglycemia Miller ME, et al. BMJ. 2010 Jan 8;340:b5444. doi: 10.1136/bmj.b5444.

  30. Symptoms and Signs with Progressive Hypoglycemia Blood Glucose (mg/dL) 100 90 80 Decreased insulin secretion 70 Increased glucagon, epinephrine, ACTH, cortisol, and growth hormone 60 50 Palpitation, sweating Decreased cognition, hunger Aberrant behavior Seizures, coma 40 30 20 Neuronal cell death 10 0 Moghissi E, et al. Endocr Pract. 2013;Feb 20:1-33. [Epub ahead of print].

  31. Hypoglycemia: Clinical Consequences Acute Long-term Recurrent hypoglycemia and hypoglycemia unawareness Refractory diabetes Dementia (elderly) CV events Cardiac autonomic neuropathy Cardiac ischemia Fatal arrhythmia Angina • Symptoms (sweating, irritability, confusion) • Accidents • Falls Cryer PE, et al. Diabetes Care. 2003;26:1902-1912. ADA. Diabetes Care. 2013;36(suppl 1):S11-S66. Zammit NN, et al. Diabetes Care. 2005;28:2948-2961.

  32. Treatment of Hypoglycemia: AACE/ACE Recommendations Cryer PE, et al. Diabetes Care. 2003;26:1902-1912.

  33. Elements of Hypoglycemia Prevention Moghissi E, et al. Endocr Pract. 2013;Feb 20:1-33. [Epub ahead of print].

  34. Hypoglycemia Risk With Antihyperglycemic Agents Added to Metformin Initial Treatment Additional Treatment DPP-4 inhibitors Less Hypoglycemia GLP-1 receptor agonists TZDs Metformin More Hypoglycemia Sulfonylureas Insulin (basal, basal-plus, premixed) Moghissi E, et al. Endocr Pract. 2013;Feb 20:1-33. [Epub ahead of print].

  35. Frequency of Severe Hypoglycemia With Antihyperglycemic Agents Percentage of Patients Treated in 1 Year 6% Mixtures, Rapid-acting, Basal-bolus Insulin 5% Basal 4% 3% 2% Sulfonylureas Meglinitides 1% DPP-4 inhibitors, GLP-1 receptor agonists, Metformin, TZDs 0 Moghissi E, et al. Endocr Pract. 2013;Feb 20:1-33. [Epub ahead of print].

  36. Relative Rates of Severe Hypoglycemia with Insulin Increasing rates of hypoglycemia Human insulin Analogue insulins Premixed (70/30, 75/25) Prandial and premixed Most frequent Morefrequent Basal plus 2-3 prandial Basal plus one prandial Basal + NPH Basal analogues (glargine, detemir) Pipeline basal analogues(degludec, pegylatedlispro) Lessfrequent Basal only Moghissi E, et al. Endocr Pract. 2013;Feb 20:1-33. [Epub ahead of print].

  37. Glycemic Management in Type 2 Diabetes Safety Concerns: Weight

  38. Antidiabetic Agents and Weight • Risk of additional weight gain must be balanced against the benefits of the agent • Sulfonylureas may negate weight loss benefits of GLP-1 receptor agonists or metformin • Insulin should not be withheld because of the risk of weight gain Inzucchi SE, et al. Diabetes Care. 2012;35:1364-1379. Garber AJ, et al. Endocr Pract. 2013;19:327-336. Handelsman Y, et al. Endocr Pract. 2011;17(suppl 2):1-53. Stenlof K, et al. Diabetes Obes Metab 2013;15:372-382.

  39. Glycemic Management in Type 2 Diabetes Safety Concerns: Cancer Risk

  40. Insulin and Cancer Risk ORIGIN Trial Investigators. N Engl J Med. 2012;367:319-328. Kirkman MS, et al. Presented at the American Diabetes Association 72nd Scientific Sessions. June 11, 2012. Session CT-SY13. Philadelphia, PA.

  41. Glycemic Management in Type 2 Diabetes Special Populations and Situations

  42. Management Considerations for Elderly Patients with Diabetes Impaired capacity, understanding, and/or motivation for proper self-care Increased risk of and from falling Hypoglycemia unawareness and recurrent hypoglycemia Other complicating factors • Impaired vision • Reduced strength and stamina • Sensitivity to medication side effects • Frailty • Susceptibility to hypoglycemia • Impaired counter-regulatory mechanisms • Diminished kidney function • Urinary incontinence • Status of social support and/or caregiver • Drug-drug interactions • Cognitive decline and dementia • Depression • Impaired vision Consider when establishing treatment goals Consider risks before prescribing: • Sulfonylureas and glinides (hypoglycemia risk) • Thiazolidinediones (fracture risk) • Metformin (risk of lactic acidosis with decreased kidney function) • Patient overall health and well-being • Self-care capacities • Social/family support Bourdel Marchasson I, et al. J Nutr Health Aging. 2009;13:685-691. Handelsman Y, et al. Endocr Pract. 2011;17(suppl 2):1-53. Schwartz AV, et al. Diabetes Care. 2008;31:391-396. Zammitt NN, Frier BM. Diabetes Care. 2005;28:2948-2961.

  43. Risk Considerations for Religious/Cultural Fasting Al-Arouj M, et al. Diabetes Care. 2005;28:2305-2311.

  44. Glycemic Management During Religious/Cultural Fasting • Frequent glucose monitoring—break fast immediately if patient has: • Hypoglycemia • SMBG <70 mg/dL while taking insulin or sulfonylureas • SMBG <60 mg/dLwhile on other therapies • Hyperglycemia: >300 mg/dL • Healthful eating before and after each fasting period • Complex carbohydrates prior to fast • Avoid ingesting high-carbohydrate, high-fat foods when breaking fast • Avoid excessive physical activity but maintain normal exercise routines • Avoid fasting while ill Al-Arouj M, et al. Diabetes Care. 2005;28:2305-2311.

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